Healthcare Provider Details

I. General information

NPI: 1063788925
Provider Name (Legal Business Name): MOIRA LYNN PA-C, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E CAMELBACK RD #550
PHOENIX AZ
85012-1668
US

IV. Provider business mailing address

7117 E RANCHO VISTA DR #1008
SCOTTSDALE AZ
85251-1348
US

V. Phone/Fax

Practice location:
  • Phone: 619-993-0130
  • Fax:
Mailing address:
  • Phone: 480-245-6765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberFNP 17175
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number19135
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC-0836
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP0884
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberAP0035
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1630
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP0884
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: